Healthcare Heroes Grant Request Form

GRANT REQUEST FORM

For staff needs that are not covered by county funding
NOTE
The Healthcare Hero grant is only for staff needs. Please allow 30-45 days turnaround time for your grant application. If your request is urgent, please contact the foundation at info@smchf.org or (650) 573-2655.

If your request is for something your department will use to help patients, use the Foundation Grant Request form.

If it's for one specific patient, use the Caring Hands application.
BEFORE YOU SUBMIT

Please confirm the following before submitting your grant request for Healthcare Heroes funding.
Has your manager approved the submission of your grant request?*

Yes
Please list the name of the manager who approved this submission request.*
Is this something that other departments or hospital funding cannot cover?*

YesNo
Please elaborate on how the anticipated outcome will contribute to enhancing the well-being, satisfaction, and safety of both staff and/or patients.*
The Healthcare Heroes Committee asks that the person making the grant request be willing to give a 6-month update that explains how the funded grant had a positive impact. Do you agree to share this report with a Committee member when contacted after 6 months?*

YesNo
GRANT DISBURSEMENT REQUEST
AMOUNT*
DATE*

MonthDayYear
Date
DEPARTMENT*
ORG #*
GRANT DETAILS*
CONTACT PERSON*
EMAIL*
example@example.com
DEPARTMENT*
PHONE*
Signature*

Clear
Date*

MonthDayYear
Date
FOUNDATION OFFICE USE ONLY

Please do not fill this portion out unless you are a San Mateo County Health Foundation employee.
APPROVED BY
Date

MonthDayYear
Date
Make Check Payable to
Reference
Project #
Fund
NOTE
Grant Dispersed Date

MonthDayYear
Date
Check #
Amount
Should be Empty:

GRANT REQUEST FORM

BEFORE YOU SUBMIT

GRANT DISBURSEMENT REQUEST

FOUNDATION OFFICE USE ONLY